The effect of 5 years of team sport on elderly males' health and social capital—An interdisciplinary follow‐up study

Abstract Background and Aims Floorball training induces positive effects on health among untrained older adults. However, the effect of long‐term participation (>2 years) in floorball training among elderly males has not been investigated. The aim of the present study was to examine the effect of 5 years of floorball training on risk factors for lifestyle diseases, fitness, physical function, and social capital of elderly males and compare to a control group that continued their usual lifestyle. Methods Twenty‐nine recreationally active elderly men aged 75.1 ± 3.3 (mean ± SD; range: 69–81) years with a height, body mass, and body mass index of 1.78 ± 0.06 m, 79.8 ± 10.9 kg, and 25.8 ± 4.1 kg/m2, respectively, volunteered to take part in follow‐up investigations about 5 years after participating in a study on the effect of 12 weeks of floorball or petanque training. At the end of the parental study 15 subjects chose to participate in floorball training (floorball group [FG]) whereas 14 subjects (control group [CG]), resumed their usual lifestyle. FG participated in small‐sided floorball training 1 h ~1.75 times/week for 5 years in a local sports club. Results From baseline to 5 years, FG had reduced fat percentage, android, and visceral fat, increased total and leg bone mineral density, leg extension maximal voluntary contraction, maximal walk distance in 6 min and 30 s sit‐to‐stand repetitions, decreased time for 5 sit‐to‐stand repetitions and Timed Up and Go (p < 0.05). These changes were all different from less favorable changes in CG (p < 0.05). In FG there was a decline in maximum oxygen uptake which was smaller than the decline in CG (p < 0.05). In addition, FG had developed social capital through the 5 years strengthening their social connectedness and group cohesion. Conclusion In conclusion, both from a sociological and physiological perspective, small‐sided floorball training can be considered a health‐promoting activity for older men.


| INTRODUCTION
Globally, life expectancy has increased by more than 6 years from 2000 to 2019. 1 Thus, an increasing number of elderly people will need health care, and developing strategies for increasing health and life quality among elderly people are vital.
Ageing is associated with a decline in functional capacity 1 and increased risk of developing noncommunicable diseases, such as cardiovascular diseases 2 and diabetes. 3 Thus, ageing leads to lowered ability to perform everyday tasks, increases the risk of falls, and decreases the general health profile. 4,5 Regular exercise has been shown to be beneficial in increasing functional capacity and decreasing the risk of cardiovascular disease and other lifestyle-related diseases. 6,7 Specifically team sports, such as soccer, 2 basketball, 3 and floorball 4 conducted as small-sided games, have been shown to lead to a plethora of positive health effects in both young and elderly adults, 5,6 men and women with lifestyle diseases, 7,8 healthy postmenopausal women, 9 and middle-aged men. 8 However, only a few studies have investigated the effect of regular participation in small-sided games for a period of more than 1 year. 9, 10 We studied a group of elderly people performing small-sided floorball training about twice a week for 26 months and found positive effects on maximal oxygen uptake, blood glycosylated hemoglobin (HbA1c), and leg bone mineral density. 10 In addition, it was observed that the small-sided games attract, motivate, and maintain elderly men in the activity. 11 Thus, team sport appears to stimulate physical activity for this age group. 8 Wikman et al. 12 also showed that floorball arranged as small-sided games had a positive effect on the participants' social capital, due to a high degree of solidarity and group cohesion. 12 Social capital is defined as social networks and the associated norms of reciprocity. 13 According to Putnam,13 social capital is particularly generated in communities centered around activities such as choir groups or sports associations. Thus, participation in small-sided floorball may have positive benefits for the development of social capital especially if it is conducted in a sports club. Other studies have also shown that interventions conducted in groups can be effective in preventing loneliness and social isolation. 14 In the present study, we investigated the long-term effect of small-sided team sports on social capital, by using I-, We-and They-Stories, 15 as the long-term effect has never been investigated, and it is not known if the effect of small-sided team sports on social capital is levelling off after several years. The long-term effect of small-sided team sports on social capital is important as social capital has a large impact on health. 13 The present study is a product of a successful implementation based on the original 12-week training study 8

| Subjects
This study is part of a parental study. The subjects were recruited from a study by Vorup et al. 8 (referred to as the original study), which examined the effect of 12 weeks of floorball training and petanque training on blood lipids, muscle strength, body composition, and functional capacity of men aged 65-76 years.
Twenty-nine subjects from the original study aged 75.1 ± 3.3 (mean ± SD; range: 69-81) years with a height, body mass, and body mass index of 1.78 ± 0.06 m, 79.8. ± 10.9 kg, and 25.8 ± 4.1 kg/m 2 , respectively, volunteered to take part in follow-up investigations about 5 years after completing the original study.
Before the original study (baseline) the subjects were recreationally active (walking or cycling for transportation on a daily basis, and some did gymnastics, fitness, or swimming activities, but none had been involved in any type of regular (>1 weekly session) physical training for at least 10 years. This was supported by accelerometer measurements (AX3; Axivity Ltd.) showing that weekly running activity before the intervention period was low (2.02 ± 3.07 min/ week), and walking was the most popular physical activity (611 ± 217 min/week). The subjects were taking 9935 ± 3365 steps/ day, which places this group in the highest quintile in men aged >65 years with regard to steps per day. 16 For exclusion criteria, see the original study. 8 At baseline, seven subjects took medicine to lower blood pressure or blood cholesterol (four in floorball group [FG] and three in control group [CG]). There were no changes in medicine intake in FG, but in CG, two subjects started taking medicine to lower blood pressure or cholesterol, whereas one subject stopped taking medicine.
The study was approved by the Committee on Health Research Ethics, Region of Copenhagen (H-19087633), and conducted in accordance with the guidelines of the declaration of Helsinki. The subjects were informed of any risks and discomforts associated with the experiments before giving their written informed consent to participate in the study.

| Design
Eleven subjects were enrolled in the original study in September 2014 (first recruitment round) and 18 subjects were enrolled in March 2015 (second recruitment round). 8 The follow-up examination was initiated in March 2020, just before a major lockdown due to Covid-19. Thus, the follow-up time from baseline was between 5.0 and 5.5 years. In addition, there was a 2-year follow-up for the same parameters. At the end of the original 12-week training intervention, the subjects in the floorball and petanque group were given the opportunity to participate in floorball training three sessions weekly.
Fifteen subjects chose to participate in floorball training (FG), whereas 14 subjects did not participate in the floorball training (CG), and resumed their usual lifestyle. FG consisted of nine subjects from the original FG and six subjects from the original petanque group. CG consisted of six subjects from the original FG and eight subjects from the original petanque group. In FG, two subjects were excluded due to lack of participation leaving 13 in the FG. In CG, one subject passed away before the final tests, and one subject did not complete the final tests leaving 12 in CG. A descriptive picture of the FG players' family situation shows that 3/4 have a wife and 1/4 are alone/have lost their partner. Most of the players have children and grandchildren living close by. Several of them owns a summerhouse, where the whole family often is gathered.
We also performed a follow-up study 26 months after finishing the original study. 10 The changes from 26 months to 5 years are presented in the Supporting Information material.

| Training
In FG, training sessions consisted of small-sided floorball games 5v5 or 6v6 performed indoor on a wooden surface sized 13 × 20 m. Floorball is a team sport like field hockey, but played indoor and with plastic sticks (http://www.floorball.org). A training session lasted about 60 min preceded by a 10-min warm-up period. The training session consisted of five smallsided games with a duration of 8 min separated by a rest period of about 4 min. All training was self-organized without interference from the researchers. The subjects had the opportunity to play three times a week on Mondays, Wednesdays, and Fridays.
Interviews with the subjects showed that six subjects in CG performed regular exercise, mainly activities like running, strength training, or fitness training for 1-2 h/week. In FG, seven subjects performed strength and fitness training for 1-2 h/week in addition to the floorball training.

| Training compliance
The subjects recorded training compliance electronically. In FG, compliance the last 2 years was 1.5 ± 0.6 training sessions a week, and 1.9 ± 0.6 training sessions a week during the last 10 weeks before the 5-year follow-up examination.

| Daily physical activity
The weekly level of physical activity was determined by accelerometer measurements (Axivity) during 1 week before the final examination in October 2021. The accelerometer was placed on the thigh and carried for 8 consecutive days before removal. ACTi4 (ACTiCorp., Version 14.09) was used to discriminate between the various types of activities, including sitting, standing, walking, fast walking (more than 99 steps per minute), running, cycling, sit-tostand movements (i.e., transitions from sitting to upright stand), and number of steps based on threshold values of standard deviation of acceleration and the derived inclination. 18 The activity move (Table 4) represents activities, which were not included in the other categories. It included standing posture that is defined neither as standing still nor as walking, such as tripping, and challenging an opponent during floorball. The method used for activity recognition was originally validated with an accelerometer ActiGraph GT3X+ placed on the thigh using Acti4 software. 18 Subsequently, ActiGraph GT3X+ has been replaced with Axivity AX3, and physical behaviors were classified with negligible difference between the accelerometer brands. 19

| Interviews
The original plan was to conduct group interviews with a large group of participants, but due to Covid-19 individual telephone interviews were conducted instead in April 2020 with a sample of participants from each group. The aim was to ascertain the participants' social capital. Of the 24 participants, four from FG and three from CG were interviewed. The participants from CG were chosen randomly, while the participants from FG were those, who had the highest participation in the floorball training during the final year. The interview guide was inspired by Putnam's theory about social capital, 13 and conception of I-, we-and they-stories, and was adjusted to fit the two groups' differences. According to Putnam et al., 15 I-stories contribute to defining the individual and create communalities. I-stories are essential in building new connections, and we-stories are equally important in sustaining the new connections and create a strong collective identity. Theystories are used to create "the others" and strengthen the effect of the we-stories.
The interviews were carried out with a semistructured approach, that allowed deviation from the interview guide and comment on topics raised by the participant. 20,21 The interviews were conducted over the phone by the authors, who knew the participants because they were involved in conducting the physiological tests. All interviews were recorded and fully transcribed. The transcribed interviews were coded based on Putnams concept I-, we-and they-stories, along with additional codes emerging during the process. 20 The interviewees' anonymity was guaranteed by replacing their names with pseudonyms and all identifying information was removed. The cited quotations have been translated by the interviewers from Danish to English.

| Statistics
Comparisons of baseline outcome measures between FG and CG were performed using a two-tailed unpaired t test. Chi-square test of distribution of frequencies was used to look for differences and changes in medicine intake between FG and CG. For the considered outcome measures, the effects of floorball training compared to control were evaluated using analysis of covariance (ANCOVA) including the groups (FG and CG) as a categorical independent variable while adjusting for baseline values of the outcome, age, and medicine intake. Contrast estimates (CE), 95% confidence intervals, and p values were reported for FG and CG (see Section 3). All analyses of changes were based on comparisons of baseline before the 12-week training intervention 1 and follow-up data. The distribution of the data was checked for normality before applying the t test or ANCOVA. IBM SPSS statistics 25.0 was used for all tests. p < 0.05 was chosen as the level of significance and all data are presented as mean ± SD.

| RESULTS
At baseline, there were no significant differences between groups for any of the measurements. Table 1 shows mean and peak HR and HR distribution during 1 h of floorball training for the same eight subjects at 2-and 5-year followup. Mean percentage of HR max was 78.0 ± 8.0 and 79.8 ± 6.7% at 2and 5-year follow-up, respectively, with no difference in the distribution of HR. Lean body mass did not change in FG and tended to decrease in CG (−2.24 ± 4.5%, p = 0.09). Leg lean body mass did not change in FG, whereas it decreased in CG (−6.5 ± 5.2%, p < 0.01), with no significant difference in the change between the groups (Tables 2 and 3). No change for body mass and BMI was observed with the intervention (Tables 2 and 3).

| Bone mass and bone mass density (BMD)
FG increased total BMD (1.9± 2.3%, p = 0.04) and leg BMD (3.1 ± 2.9%, p = 0.01) during the 5-year period, which were T A B L E 1 Mean and peak heart rate as well as heart rate distribution during 1 h of floorball training for eight subjects in FG at 2-and 5-years follow-up  (Table 2 and Figure 2).  (Tables 2 and 3).
No significant effect of the intervention was observed for blood pressure and HR at rest (Tables 2 and 3 and Figures 3 and 4).

| Maximal voluntary contraction and functional capacity
There was a decrease in the maximal walking distance in 6 min in FG (−4.4 ± 9.1%, p = 0.02) during the 5-year period, which was less (p = 0.03) compared to the decrease in CG (−13.2 ± 12.1%, p < 0.01).
T A B L E 3 Values for blood pressure, blood lipids, blood glucose and insulin, and body composition at baseline and after 5 years of follow-up period for FG and CG    Figure 3 and Table 2).

| Daily physical activity
There was a tendency to an increase in daily sitting time in FG  (Table 4). year follow-up can be obtained in the supplement material (Supporting Information: Table 1).

| Social capital
For the past 5 years, FG has been practicing floorball twice a week in the local sports association. The sport association constitutes the basis for the floorball training, and thereby gives FG the opportunity for meeting others and developing social capital.

| I-stories-making us feel like equals
The  . Data are presented as mean ± SD. # p < 0. 05, compared with baseline within group. *p < 0. 05, between groups.

| We-stories-creating a community
(…) even though new people join the team they rapidly get embedded into the community and join our way of thinking and stuff like that (Poul).
The FG has generated a strong we-story through the floorball practice. The group has a shared way of thinking and norms emphasizing the development of social capital. The community is now more than just the floorball training itself and the participants meet outside practice celebrating birthdays, drinking coffee and going to museums. Their relations have evolved making their friendship close and unique as outlined by Poul: (…) there has been created something, some friendship, which I say it is also worth some kind of money.
Time has been an important factor for the creation of the strong westory as outlined by Putnam and Feldstein. 15 The FG has continued to develop their relations through the 5 years and their community is more important today than when they started the intervention. Harry, who was part of the FG the first one and half year, stresses this: (…) if you look at a person's character as a spectrum, then I only got to know a small part of it (…) you didn't get to know each other that well through that floorball.
An indicator of the strong community in FG is that, during the coronavirus pandemic, they still maintain their connections: (…) they have sent some pictures and selfies, but it will never really be the same (…). George.
They stay in touch even though they do not have their normal arena for social interaction and opportunity of face to face contact, which is important for the development and maintenance of social capital. 15 This underlines the network and social capital as an outcome of the floorball training.

| They-stories-finding differences
It has not been necessary for the FG to create a definite "the others" in the development of social capital although it can strengthen the effect of the we-story. 15 However, the FG compare themselves with inactive peers, and in their opinion, the inactive miss out on a rewarding community as described by Poul:

| DISCUSSION
The main findings of the present study were that 5 years of floorball training performed twice a week in a local sports club led to a reduced fat percentage, android, and visceral fat, increased total and leg bone mineral density, increased functional capacity and strength, and reduced the decline in VO 2max in older men. The setup with team sport in a sports club has been an excellent frame for developing I-, we-and they identities that led to increased social capital. and elderly women playing recreational football, 22 showing reductions of total fat percentage of 1.5% to 5% 8,22 and a decrease in visceral fat of 14%. 8 High-fat percentage is associated with an increased risk of type 2 diabetes and cardiovascular disease. [23][24][25][26] In addition, visceral fat has been shown to be strongly associated with metabolic risk factors. 24 Thus, regular floorball training seems to reduce fat mass, and the activity in the recreationally active control group was high enough to counteract the expected natural agerelated increase in fat mass. Therefore, floorball training is a healthenhancing activity for elderly men.

| Body composition
FG maintained total and leg lean body mass from baseline to 5-year follow-up (Table 3). This is in line with a study of smallsided ball games showing no change in lean body mass after 24 weeks of football training. 2 This might be due to the amount of protein intake, as protein intake immediately after, as well as 3 h after ball play, has been shown to promote hypertrophy in older individuals. 27 However, the diet was uncontrolled in the current study, and therefore it remains unclear whether protein intake after the training sessions would have increased fat-free mass in FG. In CG leg lean body mass decreased and total lean body mass tended to decrease. Thus, together these findings suggest a protective effect of floorball on the expected age-related decrease in lean body mass.

| Bone mass and bone mass density
Five years of floorball training led to increased leg BMD (~3%) and total BMD (~2%) in FG compared to no change in CG. This is in line with the results from the 26-months follow-up 5 and with a study by Helge et al., 28 who showed an increase in leg BMD (5.4%), but no change in total BMD after 12 months of small-sided football training.   30 showed a gradual decline in total BMD with age by an average of~0.7% per year after the age of 50. The gradual decline in total BMD with age emphasizes the importance of performing exercise that stimulates the bones. The present study showed that floorball training has the potential to increase or maintain leg and total BMD and therefore, can help to protect older men from bone injuries and fractures.

| Daily physical activity and training intensity
In FG training compliance was~1.8 times a week during the initial 26 months 10 and~1.5 times a week during the following more than 2 years, with same mean heart rate during the training sessions in the two periods, indicating that the exercise intensity was maintained (Table 1). Measurements of daily physical activity showed an increase in running time in FG after 5-year compared to baseline. In CG, the time sitting was increased, and the number of steps per day was reduced compared to baseline. Thus, there were major differences in physical activity between groups, which is presumed the main reason for the observed intervention effects.

| Maximum oxygen uptake
The smaller decrease in VO 2max in FG (8%) compared to CG (22%) during the 5-year intervention period shows that the floorball training had a protective effect on the age-related decrease in VO 2max and, thus, significantly decreased the risk of cardiovascular mortality. 33,34 VO 2max expressed as ml O 2 min −1 kg −1 in FG did not change as the subjects had a nonsignificant decrease in body weight (  seldom is a result of exercise training but is rather due to a reduction in dietary fat. 37 According to this, it seems that the volume of training in this study was too low to stimulate changes in the lipid profile, and the decrease in plasma cholesterol in FG may have been due to dietary changes.

| Health-related blood variables
In both groups, HOMA-IR and HbA1c increased or tended to increase ( During this period, the team and the players also became more and more involved and integrated in the floorball club. They took part in the general assembly and some of the players became volunteers in the club as such.
Studies have shown that there is an inverse relationship between the amount of network and the tendency to inactivity. 40

| Floorball as a health-promoting activity for older men
Putnam describes that social capital can lead to healthier habits, which he also cites as the cause for reduced morbidity and mortality. 13 By participating in a research project lasting 5 years, participants have gained insight into the physiological benefits of playing floorball, which has probably helped increase the social capital of FG. The social capital that has developed among the floorball players had at the same time also made the participants in FG committed and persistent, which led to further training and physiological adaptations. The effects are an increased functional capacity and strength, and a reduced risk of lifestyle-related cardiovascular diseases. Thus, the participants' increased social capital and physiological adaptations seem to have a reinforcing effect on each other. Therefore, from a combined sociological and physiological perspective, floorball in local sports clubs must be considered a health-promoting activity for elderly men.

| Limitations of the study
The study has some limitations that should be highlighted. For the physiological and functional tests, the sample size was smaller than in the original study, which might have resulted in type II errors. The number of participants in interviews was fewer than originally planned, which was caused by the lockdown due to Covid-19, resulting in telephone interviews instead of the planned group interviews. Covid-19 might also have influenced the results of the tests of functional capacity, which were delayed until participants had resumed their normal lives, including floorball training for 3 months after lockdown throughout the spring of 2021. For ethical reasons, it has also not been possible to maintain the randomization from the original 12-week study. The participants chose their preferred group.
Despite this, there was no difference at baseline in any of the physiological and functional tests. Therefore, the effects are described from baseline to 5 years instead of from 12 weeks to 5 years, despite the fact that some participants played floorball for 12 weeks after baseline. However, the original petanque players in the present floorball group did not play floorball from baseline to 12 weeks. We have chosen to ignore the effect of the training these 12 weeks, as the effect after 5 years can be considered negligible.

| Summary
The present study showed that 5 years of floorball training performed twice a week in a municipality setting led to a more favorable body composition (reduced fat percentage, android, and visceral fat), increased total and leg bone mineral density, increased functional capacity, and strength, reduced the decline in VO 2max and increased social capital in elderly men. FG progressively developed social capital through the 5 years, strengthening their social connectedness and group cohesion. Taken together, the present study showed that floorball in a local sports club can be considered a long-lasting health-promoting activity for elderly men.

| Perspectives
This present study highlights that social capital can increase over years, increasing social connectedness and group cohesion, with a lasting physiological health effect after 5 years. Therefore, floorball as a small-sided game should be offered to the elderly in municipal contexts. Future sociological research should deal with two subjects; first, investigate how a research intervention successfully can work as a health prevention program and be included in a local sports club.